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On the Origin of the Human Treponematoses (Pinta, Yaws, Endemic Syphilis and Venereal Syphilis)

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On the Origin of the Human Treponematoses (Pinta, Yaws, Endemic Syphilis and Venereal Syphilis) Bull. Org. mond. Sante 1963, Bull. WldHlth Org. 29, 7-41 On the Origin of the Human Treponematoses (Pinta, Yaws, Endemic Syphilis and Venereal Syphilis) C. J. HACKETT, M.D., F.R.C.P.1 A close relationship between the four human treponematoses is suggested by their clinical and epidemiological characteristics and by such limited knowledge ofthe treponemes as there is at present. No treponeme of this group (exceptfor that of the rabbit) is known other than in man, but the human treponemesprobably arose long agofrom an animalinfection. The long period cfinfectiousness ofpinta suggests that it may have been the earliest human treponematosis. It may have been spread throughout the world by about 15 000 B.C., being subsequently isolated in the Americas when the Bering Strait wasflooded. About 10 000 B.C. in the Afro-Asian land mass environmental conditions might have favoured treponeme mutants leading to yaws; from these, about 7000 B.C., endemic syphilis perhaps developed, to give rise to venereal syphilis about 3000 B.C. in south-west Asia as big cities developed there. Towards the end of the fifteenth century A.D. a further mutation may have resulted in a more severe venereal syphilis in Europe which, with European exploration and geo- graphical expansion, was subsequently carried throughout the then treponemally uncom- mitted world. These suggestions find some tentative support in climatic changes which might have influenced the selection of those treponemes which still survive in humid or arid climates. Venereal transmission would presumably remove the treponeme from the direct influence of climate. The author makes a plea for further investigation of many aspects of this subject while this is still possible. CONTENTS THE DISEASES . 8 EVOLUTION OF THE TREPONEMATOSES . 21 The human treponematoses . 8 Origin of human infections . 21 Course of the human treponematoses . 10 Infectious contacts in man .... 22 Pathological characteristics of the human tre- Size of community needed to maintain infections 22 ponematoses .............. 14 ORIGIN OF THE HUMAN TREPONEMATOSES . 23 Prevalence of the human treponematoses . 14 Geographical distribution of the human trepone- Step 1-Pinta .... 24 matoses . 15 Step 2-Yaws . 26 Animal treponematoses . 18 Step 3-Endemic syphilis . 27 Step 4-Venereal syphilis . 28 THE CAUSAL ORGANISMS . 18 CONCLUSION ..... 30 The pallidum/pertenue treponemes . 18 Site of entry and transmission of the treponemes 19 RisUM1 .................. 38 Other treponemes in man and nature . 21 REFERENCES ..... 39 I Senior Medical Officer, Research Planning and Co-ordination, World Health Organization, Geneva, Switzerland. 1274 -7- 8 C. J. HACKETT The human treponematoses comprise four closely- a long period of infectiousness and is geographically related infections: pinta (mal del pinto, carate), isolated in the Americas from the other treponema- yaws (pian, framboesia, bouba), endemic syphilis toses. Its causal organism, Treponema carateum, is (bejel), and venereal syphilis. More information the only one of the four treponemes with which is needed before their origins can be traced with animals have not yet been infected experimentally. confidence. However, consideration of this interest- These characteristics distinguish pinta from the other ing question may indicate relevant studies to pursue. three treponematoses. The first four sections of this paper summarize The other subgroup contains yaws and endemic various aspects of the problem and the fifth contains syphilis. These, like pinta, are diseases of less- some suggestions based upon existing knowledge developed rural populations and are usually con- and reasonable assumptions.' tracted in childhood. Between yaws and endemic It is hoped that this brief survey will stimulate syphilis are certain clinical and epidemiological constructive action while this is still possible. differences. Typically, endemic syphillis occurs in warm, semi-arid and arid areas and yaws in warm THE DISEASES countries with higher rainfall and more vegetation. As a rule, neither of them is endemic in urban popu- The human treponematoses lations nor do both occur in the same population The four treponematoses in man are caused by (see page 12). In both, poor standards of hygiene organisms which are microscopically indistinguish- are important. able by present techniques. The appearance of the There is little need here to describe the venereal Treponema pallidum, which Schaudinn in 1905 des- disease of urban populations in any climate, syphilis. cribed from the lesions of venereal syphilis, is typical It,was, until recently, a serious public health problem of them. of advanced countries and caused much suffering These four human treponematoses 2 may be and disability (see page 13). The severe late lesions grouped according to the usual way they are trans- of the heart, nervous system and eye appear to mitted, as follows: differentiate venereal syphilis from the non-venereal (1) Non-venereal (often called endemic) trepone- treponematoses (Table 1). However, the frequency matoses; transmitted mostly among children: of these lesions in venereal syphilis in Africa in the Pinta past was thought to be low, but Limbos (1957) com- (a) ments upon the occurrence of central nervous system (b) Yaws involvement in syphilis there. Endemic 3 syphilis The pattern of venereal disease in Africa may have (2) Venereal (sometimes called sporadic) trepone- changed in the last 15 years. Many of the present matosis; transmitted mostly among adolescents inhabitants of large African cities have come from and adults: the country, where they might have had yaws in Venereal or sporadic syphilis. childhood. The seroreactor rate in urban primiparae In the first group are two subgroups. One consists in several tropical African countries is about 20%, of pinta, which has different clinical manifestations, but congenital syphilis is often infrequent. This may be because childhood yaws protects against adult 1 Much help has been received from the constructive infection with venereal syphilis. However, in Dakar, criticism of many friends during the past four years. which is just north of the yaws area, Senecal et 2 In this paper each of the four treponemes and the four diseases related to them are regarded as different entities. al. (1962) have reported 10 %-15y% seroreactors Hudson (1946, 1958) has, however, strongly contended among pregnant women and estimated 20% con- that all the treponemal infections comprise one disease, treponematosis, which is caused by one treponeme, T. palli- genital syphilis among children. They also found dum, " which presents different clinical patterns under that about 11 0 of children born of seroreactive different climatic and sociological conditions". mothers who were not treated during the pregnancy 3Since the name " endemic syphilis " still causes con- fusion because the significance of the " endemic " is often were also seroreactive with or without clinical signs. missed, another name for this disease is needed. Local Intra-uterine transmission in venereal syphilis and names, such as bejel, are not suitable. In general, endemic syphilis is a treponematosis of arid areas and thus the name its absence in the endemic treponematoses are per- " treponaridosis " might be suggested because it is the haps not important in the differentiation of those treponematosis of arid countries. Were a new name needed for yaws, which it is not, the name "treponumidosis" might diseases because in venereal syphilis this transmission be proposed. is also unusual when the mother has been infected ON THE ORIGIN OF THE HUMAN TREPONEMATOSES 9 for more than five years. However, women with historians is to know how soon venereal syphilis may florid early infectious yaws have been reported to enter such populations when the indigenous endemic have borne healthy children (Baermann, 1911). treponematosis has been eradicated. The unlikelihood of venereal syphilis occurring in The differentiation of venereal syphilis and yaws populations infected in childhood with yaws or has been discussed by Stannus (1926, 1936), Black- endemic syphilis casts doubt upon early reports of lock (1932a, 1932b), Turner (1937) and Turner & venereal syphilis in populations later found to have Hollander (1957). The solution of this problem high prevalences of these diseases. This must be kept must await the fuller study of the antigenic constitu- in mind in interpreting such reports in relation to tion of the treponemes. historical medical geography. A growing problem Some clinical characteristics of these four infec- for present public health workers and future medical tions are listed in Table 1. TABLE I SOME CLINICAL CHARACTERS OF THE TREPONEMATOSES Character Pinta 1 Yaws Endemic | Venereal ~~~~syphilis~~ ~~s yphilis Usual source of treponemes Skin anywhere Skin anywhere Buccal mucosa Genital and mucosal lesions Size of infectious area Large Large Small Small Duration of: Infectiousness of individual lesions Many years A few months A few months A few months Infectiousness of patients, including infectious relapses Many years 3-5 years 3-5 years 3-5 years Latency f Absent Characteristic Characteristic Characteristic Lesions: Initial, site Exposed skin Skin of legs Mouth ? Genital Initial, occurrence Infrequent Frequent Unusual Frequent Generalized skin, extent Extensive Extensive Limited Moderate Genital, occurrence Unusual Scanty Scanty Frequent Buccal mucosal, occurrence Absent Scanty or absent Moderate Scanty Palmar and plantar hyperkeratoses,
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